◆ Important Notice — Email Communication
By returning this questionnaire by email you acknowledge and consent to the communication of your personal and medical information via email. While reasonable safeguards are in place, email is not a fully secure method of communication and may be vulnerable to interception or unauthorised access. If you prefer not to communicate medical information by email, please call the office at 613·591·1188 to arrange an alternative. Participation is voluntary and will not affect the care you receive.
◆ Section I — Patient Information
Tell us about you.
Basic information so we can prepare for your consultation.
Hand dominance (left or right)
Smoking & vaping status
Never smoker
Current smoker
Ex-smoker
Vape / nicotine pouch
Alcohol use (frequency and amount)
◆ Section II — Medical & Surgical History
Your medical background.
Please list all relevant items. If none, write “none.”
Medical conditions (e.g. diabetes, high blood pressure, liver disease, epilepsy, thyroid, autoimmune, clotting disorders)
Previous surgeries & year
Anaesthesia history (any reaction, nausea, or family history of malignant hyperthermia)
Current medications (prescription, OTC, hormones, supplements, herbal)
Allergies (medications, latex, tape, foods — and the reaction)
◆ Section III — Hand Disease History
Family history of Dupuytren's?
Previous treatments for Dupuytren's (steroid injections, needle aponeurotomy, fasciectomy, enzymatic dissolving, or none)
Previous imaging studies (ultrasound, MRI, or none — include findings if available)
◆ Section IV — Symptoms & Functional Limitations
How Dupuytren's affects your daily life.
Tick each symptom you experience. For pain and stiffness, rate 1–10 where 10 is most severe.
Hand pain
Finger stiffness
Finger contractures (bent posture)
Difficulty straightening fingers
Weakness in gripping
Difficulty with fine motor tasks
Difficulty writing / typing
Difficulty with self-care (washing, dressing)
Impact on work / profession
Cords / nodules visible in palm
Disease progression (worsening)
Cosmetic concern about appearance
Which activities are most affected? (be specific about what you struggle with)
Contracture severity (How far can affected fingers straighten? Or describe limitations)
◆ Section V — Treatment Goals & Preferences
What outcome would feel right for you?
These preferences guide our discussion. Nothing here is binding — all choices are finalised together at your consultation. If unsure, tick “discuss in consultation.”
Primary goal for treatment (select what matters most)
Restore function (straighten fingers)
Reduce pain
Cosmetic improvement
Prevent progression
Combination of above
Discuss
Scar/cosmetic concerns
Minimal scarring is important
Function over appearance
Both equally important
No specific concern
Recovery timeline expectations (range of acceptable recovery time)
In your own words — what would a great result look like?
Is there anything that worries you about treatment?
◆ Section VI — Occupation & Lifestyle
Your life outside surgery.
Recovery planning is individualised. Telling us about your day-to-day helps us tailor post-operative care to you.
Occupation & physical demands (role, how much hand use is required, employer accommodations)
Planned time off work
Less than 1 week
1–2 weeks
2–4 weeks
More than 4 weeks
Flexible
Other daily hand demands (sports, hobbies, caring for children/dependents)
Home support after surgery (help available for first 48–72 hours, assistance with daily tasks)
Caring for young children or dependents?
Yes — young children at home
Yes — other dependents
No
Timing & events (travel, events, deadlines within 3–6 months)
How did you hear about Dr. Jaberi?
Referring physician
Friend / family
Instagram
Google
Website
Other
Anything else you would like Dr. Jaberi to know?
I confirm that the information I have provided is accurate to the best of my knowledge. I understand that complete and truthful disclosure is essential for my safe surgical care.